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Healthcare Insurance Industry’s’ New Business Model Is Wrong.

February 29, 2012
inConsumer Driven Health Care, Healthcare Insurance Industry, Medicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

One percent of the people spend 25% of the healthcare dollars. Twenty percent of the people spend 80% of the healthcare dollars.

It would be important to know why this is true. Then figure out what could be done about it Stakeholders need to agree on a course of action.

It would be a good idea to understand what physicians think should be done. 

“One percent of patients account for more than 25 percent of health care spending among the privately insured, according to a new study. Their medical bills average nearly $100,000 a year for multiple hospital stays, doctors’ visits, trips to emergency rooms and prescription drugs.”

The 1% and the 20% are suffering from complications of a chronic disease.

The incidence of chronic diseases is on the rise in the United States. A major precipitating factor for this is obesity.

The incidence of Type 2 Diabetes Mellitus is increasing in both adults and young children, as the incidence of obesity is increasing.

The incidence of complications of Diabetes Mellitus will increase in the future. The result will be an increase in the cost of medical care.

President Obama’s healthcare reform act will expand healthcare coverage to 32 million uninsured in 2014. Obamacare is forcing the healthcare insurance industry to change its business model in order in order to remain profitable.

Premiums are out of the reach of most businesses and individuals. Premium increases are not an option.

High-risk individuals are denied healthcare insurance coverage. High-risk patients automatically get coverage in corporate healthcare plans. The healthcare insurance industry simply raises premiums on corporate groups in order to maintain its profits.

Something must be done to decrease the increase in chronic disease and its complications. 

The government cannot afford to insure its present patient obligations much less the 32 million uninsured.

“As the new federal health care law aims to expand care and control costs, the people in the medical 1 percent are getting more attention from the nation’s health insurers.”

Twenty percent of the population not 1% should be getting the attention of the healthcare insurance industry.

“Studies have already shown that Medicare spending is concentrated on a small group of individuals who are seriously ill.

An analysis by the IMS Institute for Healthcare Informatics, the research arm of IMS Health, a health information company in Danbury, Conn., provides a rare glimpse into the medical problems of people with private health insurance that are under 65.

About three-quarters of them suffer from at least one chronic condition that could spiral out of control without proper care.”

Most of these people were obese.

The healthcare insurance industry cannot avoid these patients after 2014.

“Insurance companies will be required to enroll millions of new customers without the ability to turn them away or charge them higher premiums if they are sick. They will prosper only if they are able to coordinate care and prevent patients from reaching that top 1 percent.”

The healthcare insurance industry realizes it must fundamentally change its business model.

The healthcare insurance industry has a problem developing a new business model that would work. The industry does not want to lose control over patients, their physicians and the monies paid into the healthcare system.

The healthcare industry does not have a clue about how to actually repair the healthcare system. It is focused on its own bottom line rather than looking at business models that will be beneficial to everyone and align all the stakeholders’ incentives.

The healthcare insurance industry is planning on instituting programs that will tinker with the edges. It will not fix the problems.

The new business models will increase the percentage of money the insurance industry receives for direct patient care maintaining a Medical-Loss ratio of 15%. There is no interest in providing patients with financial incentives and a choice.

The net result will be higher costs and system failure. The weird thing is most of the healthcare insurance industry executives know it.

“The reality is if we don’t figure out how to get to the patients, we’re not going to get where they need to be,” said Dr. Lonny Reisman, the chief medical officer for Aetna.

The reality is that the system must be consumer driven with consumers in charge of their healthcare and their healthcare dollars.

At the moment patients have no incentive to decrease the cost of care. Hundreds of patients have told me that they go to the doctor to fix their illness. Medicare or their insurance pays. The patients have no idea of the costs they incur nor do they care. They have no interest in controlling their disease.

My ideal medical saving accounts would give the patients incentive to learn about their disease. They would be interested in self-managing their disease with the physician and his medical care team being the coach.

“The next challenge, say insurers, is to figure out how best to work with a person’s doctor. Because many of these patients seem to be seeing many doctors and taking many medications, there may be no one who is accountable for the patients’ overall health.” 

Physicians have figured out what services get paid by the healthcare insurance industry. They do not get paid for educating patients about their disease.

The healthcare insurance industry and the government have developed a punitive bureaucracy.   

An attempt is being made to penalize or reward physicians for medical outcomes. Pay for Performance (P4P) is a punitive payment system. It will fail. 

Patients are responsible in large part for the onset of their medical problems and in controlling their medical outcomes. Physicians cannot be responsible for patients’ outcomes. It is the responsibility of the patient.

“Insurers are also still grappling with their understanding of human nature — why some people simply don’t take care of themselves or take their medicine or go to the doctor, even when it is clear that they should.”

Patient outcomes have nothing to do with human nature. It has everything to do with financial incentive and effective education.

Spokes 5 and 6 of my future state business model has everything to do with patients’ responsibility for caring for their disease and the physicians’ responsibility to the patients. It has nothing to do with physicians’ and patients’ responsibility to the healthcare insurance industry or government.

The opinions expressed in the blog “Repairing The Healthcare System” is, mine and mine alone

Please send the blog to a friend

 

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How Could A Social Networking Company Make Money In Healthcare?

February 22, 2012
inChronic Disese Management, Consumer Driven Health Care, Medicine: Healthcare System
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Stanley Feld M.D.,FACP, MACE

My last blog about individual healthcare insurance policies generated a lot of comments from young people starting up a business and individuals operating their own business at home. I also received several from entrepreneurs looking to start a business.

One person wrote,

"Dear Dr. Feld

So we have now learned that high deductible plans are what people should be purchasing. We also learned that they should be self insuring for $10,000 which is the highest deductible insurance at the lowest price.

 Over $10,000 is where are at the greatest financial risk. True insurance should cover our greatest risk.

I would like to know where is the business opportunity is for an Internet company that runs social networks?

 

 

 Sincerely

Z"

I said the world belongs to young people 20-50 years old. They also understand the power and mechanics of social networking.

If there was a social network dedicated to describing the advantages and disadvantages of the healthcare insurance options available to the unemployed, self- employed and under insured there would be many members. If those members had the ability to have input it would grow even larger with appropriate marketing.

I have not figured out how social networking sites make money except through advertising. I imagine many companies would like to get the attention of these consumers who are seeking healthcare insurance advice.

It has been reported that people change their job up to 8 times during their career. More and more people are in start-up businesses and need healthcare insurance for their employees. Many people are becoming consultants and are self-employed. They all need healthcare insurance for their family.

President Obama’s answer to the problem is the government will provide the healthcare insurance for you. Healthcare insurance is a right as an American.

There are several problems with this statement. The government cannot afford to provide adequate healthcare insurance for the entire population.

Britain has proved it. They are reverting back to a pay for service system. The socialist democrats in Europe have proved that. Each country is going bankrupt.

The business opportunity would be to teach the people who are self-insured or uninsured about the rip off of the healthcare insurance industry and to teach them how to save money.

How many start up companies do you guess are uninsured or under insured or not insured for catastrophic illness because they cannot afford the healthcare insurance premiums?

The chances are many start up employees will not get sick. True healthcare insurance should be a hedge against catastrophic illness.

If someone gets sick in a company, the company could pay the employee for the amount he spent before they reached the full deduction.

The high deductible individual policy is not tax deductible. If it were made tax deductible by citizen demand to congress through social networking the voice of the individual could be heard. Congress might be forced to act.

Start up companies and other companies would save money. These companies would be placed on the same playing field as companies who pay for employee insurance with pre tax dollars. The social network could even form an association of self-employed companies and enjoy the tax benefits and purchasing power of large corporations.

This would represent a threat to the healthcare insurance industry. They would do everything to stop. So would the government.

If you do the math for the government, the government would be saving much more money than it would collecting taxes. 

An appropriate social network could stop the healthcare insurance industry's grotesque business model in its tracks.

It could save billions of dollars. It could create incentive for people to take better care of themselves. 

Many large and small companies are self-insured. The law lets these companies deduct their healthcare insurance with pre tax dollars. These companies could offer my ideal medical saving account with a $7,500 trust account. They could then reinsure employees for over $7,500 with a reinsurance company. 

Employees would obtain first dollar coverage after the deductible is reached.

In the worst case the company would save $6,000 per employee. In the best case it would save $13,000 per employee.

http://www.lijit.com/search?uri=http%3A%2F%2Fwww.lijit.com%2Fusers%2Fstanleyfeld&start_time=&p=g&blog_uri=http%3A%2F%2Fstanleyfeldmdmace.typepad.com%2F&blog_platform=&view_id=&link_id=7386&flavor=&q=ideal+medical+savings+accounts&x=0&y=0 

I suspect even the traditional insurance companies would provide the re-insurance.  These healthcare companies have already negotiated fees with physicians, hospitals and drug companies. 

If the healthcare insurance industry did not provide re-insurance its negotiated fees could be obtained easily.

A bank or a mutual fund could adjudicate the claims instantly.

The large corporations, who are self-insured, all have HR officers. The HR officers I have met either do not seem to have the bandwidth to investigate the possibility of the ideal medical saving account structure or they are trapped into outsourcing the details of the corporation’s self-insured healthcare plans to middlemen. I have a feeling the commitments of some with middlemen are long term.  

If all this could happen it would be an important first step in the development of social networking in healthcare and medical care.

Consumers need education for the care of their chronic disease such as diabetes, asthma, chronic lung disease, heart disease and chronic gastrointestinal diseases. Many of these diseases are a result of obesity.

If social networking could discourage the ever-increasing incidence of obesity, society would decrease healthcare costs dramatically. 

If patients learned how to manage their own disease the cost of medical care would decrease precipitously.  

Why?

Because 80% of the healthcare dollars spent on direct patient care are spent on the complications of chronic diseases that are not well managed by patients.

Many drug companies and medical device companies would advertise on these social networking sites.  

Consumers must drive the healthcare system in order for the healthcare system to be repaired. Not government or the healthcare insurance industry.

Consumers feel powerless at present. Empowering consumers through social networking will disrupt the entire healthcare systems supply chain for the better.

Consumers are up against a government that wants to tell them what they have to do. They are up against healthcare insurance companies that charge obscene premiums. They are up against hospitals, physicians and emergency rooms that have exorbitant charges.

Consumers are up against diseases such as obesity which precipitates many chronic diseases.

Consumers are frustrated and need leadership and guidance.

The phenomenal growth in social networking can give consumers the tool they need to control their health and drive the healthcare system.

Social networking is the only way to start a consumer driven healthcare movement. It has to happen before the medical care system is destroyed.

The young people expert (20-50 years old) in social networking have to become engaged. 

Those young people have to understand physician mentality and the importance of the patient physician relationship.

I will be happy to help in any way I can.

 

The opinions expressed in the blog “Repairing The Healthcare System” is, mine and mine alone

Please send the blog to a friend

 

 

 

 

 

 

 

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The Fourth Spoke In the Business Model For A Successful Healthcare System

February 15, 2012
inEMR, Medicine: Healthcare System
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Stanley Feld M.D.,FACP,MACE

The fourth spoke of a successful healthcare system’s business model is my Ideal Electronic Medical Record (EMR). I have been speaking about the Ideal Electronic Medical Record since 2006.

Slide17

I have been an advocate of EMRs since 1992. An appropriately designed user friendly EMR would improve workflow efficiency, increase physicians ability to communicate with patients, hospitals and other physicians and reduce costs. Presently it costs physicians $7 to pull a chart.

There have been many EMRs built by many technology companies in the last 20 years. The price of an EMR has ranged from $ 5,000 to $120,000 per physician. The practice disruption to install a new system has been unbelievable.

Hospital system costs to install EMRs have ranged from $500,000 to $5 billion dollars.

In 2007 the deficiencies in Kaiser’s EMR were exposed to the chagrin of the Kaiser board of directors.  

“Kaiser: Critical Need To Cut Rising Costs”

“$7 billion in losses if no action taken, HMO report says”. Kaiser has invested $3 billion in data system created by Epic Systems Corp. Kaiser’s project supervisor e-mailed 180,000 employees detailing his frustration with Kaiser’s Electronic Health Record System, which he considers inefficient and unreliable. The project supervisor brought his concerns to the Kaiser HMO’s board. He said the information was not taken seriously “because of conflicts among top executives.” Doesn’t this sound typical of the hierarchical bureaucratic systems we live in?  

The creation of a fully functioning electronic medical record is extremely complicated. Physician practices and hospitals have different needs.

If hospital administrators are choosing a company to build the EMR invariably the software company builds the EMR for the payer (hospital). The hospital is their customer.

The physicians on staff are not their customers. Patients and physicians are their real customers but they are not considered the customer. The EMR should be built for patients’ benefit. It should be built to improve the patient physician relationship.

The EMR must be designed so that it does not interfere with the physicians' workflow and improves physicians’ care of patients.

The only way this is going to happen is if consumers are responsible for their health and healthcare dollars. Consumers will then drive their physicians to obtain a fully functional EMR.

Little progress has been made in getting large numbers of hospitals and physicians to install EMRs. There are many reasons for this dilemma.  The principle reason is cost.

As the government and the healthcare insurance industry decrease reimbursement to hospitals and physicians, hospitals and physicians are hesitant to make large capital investments for EMRs.

As of 2010 only 12% of US hospital have installed at least basic EMRs. Only 2-3% might qualify for having fully functional EMRs. A fully functional EMR has to meet 23 to 25 of government imposed criteria. In 2012 these criteria define “meaningful use” developed by President Obama’s healthcare administrators.

The "minimal use criteria" will become more complex by 2014. This means the cost of upgrading an EMR will increase. Converting from ICD-9 to ICD-10 will add to the upgrading costs.

The government bureaucracy has added another gigantic hairball in the middle of the patient physician relationship.  

Government bureaucrats looking at the healthcare system believe in fully functioning EMRs. Some hospital and physicians in small practice cannot afford the prices of EMRs despite the $27 billion dollar subsidy President Obama included in his Economic Recovery Act.

The $64,000 dollar maximum per physician subsidy, if they qualify, is less than the cost of the functioning EMR cost. The millions of dollars in hospital subsidy don’t match the billions of dollars in costs, service, upgrades and maintenance needed by hospitals for a functioning EMR.

No one in President Obama’s ever expanding government healthcare bureaucracy ever thought of putting an Ideal Electronic Medical Record in the cloud and charging the physicians and hospital 1 penny per click per month.

This formatting of the Ideal EMR would align the incentives of the government, hospitals, physicians’ practices and patient care.

There would be a universal EMR with automatic upgrades, maintenance and service.

Organizations that have spent a lot of money would move over to the system because they would avoid service contracts, maintenance fees and the cost of upgrades.

All the software the government felt was necessary to make the Ideal EMR completely functional would be in the system. New regulations necessitating added software would be incorporated into this Ideal Electronic Medical Record.

Practice Fusion is a new website that provides an electronic medical record for free to physicians. It is sponsored by ad revenue.

 

 

This website might have struck gold. It has grown from 10,000 users to 50,000 users in the last two years. It has meaningful use criteria embedded in the software program.    

The You Tube and its accompanying You Tubes explains the system. It is easy to set up. It is free and seems secure. I still have some questions. However Practice Fusion might be right on target.

Remember, online banking did not take off until it was free.  

 Practice Fusion might be the disintermediator of the electronic medical records industry in healthcare just as ITunes was the disintermediator for the music industry.

Whoever said physicians are not computer literate was wrong. The only way the healthcare system is going to be fixed is if patients and physicians take the initiative without government and its bureaucratic complexity or interference.

The opinions expressed in the blog “Repairing The Healthcare System” is, mine and mine alone

Please send the blog to a friend

 

 

 

 

 

 

 

Practice fusion

 

 

 

 

Practice fusion tours.

http://www.youtube.com/watch?NR=1&feature=endscreen&v=pVYdPcqlSf8

 

http://www.youtube.com/watch?v=PCk1V2uuq1o&feature=related

 

 

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Healthcare’s Impending Software Revolution

January 11, 2012
inInformation Technology in Healthcare, Medicine: Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

It is clear to me why the healthcare industry has not experienced the same transformation resulting from software innovation that the publishing industry, the music industry and the movie industry have experienced.

After practicing Clinical Endocrinology for 30 years as the founding partner of Endocrine Associates of Dallas P.A. and as President of the American Association of Clinical Endocrinologists, I believe I understand the reasons the healthcare industry has not be able to break through and enjoy the economies of scale offered by the software revolution.  

I have formed these opinions by dealing with local and national hospital administrators, healthcare insurance executives, pharmaceutical executives, healthcare policy wonks and government bureaucrats.

Most of these executives are focused on the wrong customer. Most are too busy trying to solidify their perceived position of power in the healthcare system.

Those executives who understand who the customer is have kept quiet in order to maintain or advance their position in various organizations.

The result is software innovators have been chasing the wrong customer. The result has been greater dysfunction in the healthcare system.

There are also many healthcare system issues making it very difficult to stay focused on the main problem.

I have been fascinated by my son Brad Feld’s insight into the software industry.  His tutoring has helped me learn how to critically think about software development and its transformational potential.

My brother, Charlie Feld, has also helped me through his insight into pattern recognition and the use of information technology to solve the problems of various industries.

I have followed the progress of medical software innovation for the last three decades. I am still far from expert but believe I have a better grasp on the problem than most.

I have a good feel for the potential offered by this software revolution for the practice of medicine and how to use it.

If the software industry understood the physician mentality and understood the real customer, the needed breakthrough could occur.

The result would be a large decrease in the cost of healthcare.

Waste, abuse and overuse would be decreased and the therapeutic effect of the patient physician relationship would be restored.

I believe the medical software is available right now. It has to be manipulated and synthesized as Steve Jobs, Jeff Bezos and Mark Zuckerberg have done in their respective software areas.

Brad is not interested in healthcare system software innovation. He dealt with physicians and dentists when he ran Feld Technologies in 1985 while a student at MIT.

He built an interoffice and intra-office network for my practice Endocrine Associates of Dallas P.A. in 1985.  He hired MIT students to write software with him and Dave Jilk.

The network these kids built was the sturdiest Medical Systems network in Dallas. The network lasted from 1985 until 2002. There are still remnants of this software in the practice today.

When he finished my software project he pledged to himself he would never deal with physicians again. He concluded that they are all a pain.

Not true. Physicians know what they want and need. They have an awesome responsibility for their patients’ lives and privacy.

Secondary stakeholders have frequently taken advantage of the medical profession and its intellectual property. Physician mistrust of secondary stakeholders is monumental. 

Much of the “data collected” from information systems has been used against them even if the data is incorrect or incorrectly interpreted.

Healthcare policy has been formulated on inaccurate data and inaccurate conclusions.

These conclusions have been used to devalue physicians and to destroy the patient physician relationship.

Healthcare software companies are paid by secondary stakeholder to create innovative software. The software companies do not realize that the real customers are patients and physicians. These companies do not understand why they cannot get patients and physicians to cooperate.

When data collected is wrong, incomplete or misunderstood physicians protest. They are ignored. The typical response is that this is the only data available.

Healthcare policy should not be formulated on the bases of false data.

 Is it any wonder that physicians are not interested in cooperating with the powers that be in the healthcare system’s use of inaccurate data?    

The medical transaction must be between the patients and physicians. All of the secondary stakeholders have jumped into the center of this transaction to control the healthcare system. The secondary stakeholders only add value at the edges of the patient physician transaction. 

Our health is our most precious asset. Americans are willing to pay as much as necessary for medical care. They want everything done especially if they are not responsible for paying for it.

If physicians do not think something should be done they can get sued. The knee jerk reaction is to do everything.

Physicians only receive between 5-10% of the healthcare dollars.  

Where is the money going? Secondary stakeholders are ripping off the healthcare system as they undermine and undervalue the patient physician relationship.

Third parties have taken control of the healthcare system. They have assumed responsibility for the healthcare of patients. They are also in the process of dictating access to care. The present increased healthcare costs are unsustainable.

All the secondary stakeholders are like a giant hairball destroying the viability of patient physician relationships.

Innovative software used properly can disassemble the elements of the hairball and drive them to the edges of the healthcare system where they belong.

Proper software innovation can accomplish the goal of decreasing costs and increasing the quality of care by restoring the patient physician relationship.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

Please send the blog to a friend 

 

 

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The Healthcare System vs. The Medical Care System

December 14, 2011
inHealthcare Insurance Industry, Medicaid, Medicare, Medicine: Healthcare System, Stakeholder Mistrust
• Leave a comment

Stanley Feld M.D.,FACP,MACE

The difference between the healthcare system and the medical care system is very clear to me. The stakeholders in the healthcare system are patients, physicians, government, hospital systems, pharmaceutical companies, pharmacies, pharmacy middlemen, and healthcare insurance companies. 

 Government, hospital systems, pharmaceutical companies, pharmacies, pharmacy middlemen, and healthcare insurance companies are secondary stakeholders in the healthcare system.

 The primary stakeholders are patients and physicians. They also comprise the medical care system. Without the primary stakeholders there would be no need for a healthcare system.

 The secondary stakeholders have long ago taken over the healthcare system. All businesses and the government deal with the hand they are dealt using their best judgment. The people running the business or government pursue their vested interest. The difference between businesses and government is businesses work to make as big a profit as possible. Government, depending on the political party in power, pursues fulfillment of its ideology.  

 Since 1942 and the Economic Stabilization Act of President Roosevelt the market place for medical care has been distorted. In 1946 healthcare insurance was introduced. At that time the interaction between the primary stakeholders, physicians and patients, started to be destroyed by secondary stakeholders.

The cost of healthcare has progressively increased since the government passed the Medicare and Medicaid in 1965. Costs increased further in 1980 when the government said we couldn’t keep paying these increasing costs and instituted price controls for Medicare and Medicaid.

This led to cost shifting of the difference to the private healthcare insurance sector.  Businesses providing healthcare insurance for their employees accepted the resulting premiums associated with cost shifting until 1985. At that time they said, “stop.”

The healthcare insurance industry asked corporations what percentage of your gross revenue could you afford for healthcare insurance benefits. The healthcare premiums were 18% of gross revenue.

 The corporate answer was they could afford up to 12% of gross revenue. The healthcare insurance industry’s response was, no problem.

HMO pricing became the most economical option for corporate employers. HMO fixed healthcare cost for corporations and healthcare insurers.

HMOs shifted the risk to physicians and hospitals. HMOs failed because physicians and hospital did not know how to assess risk. They accepted risk initially because they were afraid to lose patients.

 Hillarycare failed to become law because of the potential for patient abuse, restrictions of access to care, rationing of care and loss of freedom of choice. Patients did not want the government to dictate their medical decisions.

 Obamacare was passed by a Democrat controlled congress with a very liberal ideology.

  Many congressmen did not read the entire document or debate the potential unintended consequences.

  The difference in ideology between liberal and conservative is easy to understand.

 “Liberals believe that health care is treated as a market commodity today but should not be, and conservatives think that health care is not treated as a market commodity but should be.”

 The healthcare system is not a true marketplace. The healthcare marketplace has been continuously distorted by government regulations and adjusted regulations since Medicare passage in 1965.

 All the stakeholders have distorted the market even further by adjusting to government regulations in order to purse their vested interest.

If real repair of the healthcare system is to occur a real marketplace has to be created. Obamacare is another adjustment in an already distorted marketplace. Obamacare is accelerating the dysfunction in the healthcare system until it implodes and results in increasing costs not savings.  

 The healthcare insurance industry controls costs. Many Democratic healthcare policy experts have ignored the facts. The healthcare insurance industry’s goal is to maximize its profit. It takes 30% of the healthcare dollars off the top.

The healthcare insurance industry should not be in control of the economics of the healthcare system.

 Consumers should be in control of their medical care decisions and the money they spend for those decisions.

Personal medical care decisions should not be left to the munificence of the government. The government has never done anything efficiently.  

 Private and Medicare insurance has kept control of medical decisions out of consumers’ hands.  Consumers purchase healthcare insurance individually or from Medicare. Consumers also can receive healthcare insurance from their employers as a job benefit.

 The healthcare insurer directs consumers to use physicians and hospital in its network. The insurer negotiates reimbursement rates for the insured with hospitals and physicians.

Consumers are given little or no information about the comparative cost or quality of any particular doctor or hospital.  Consumers go to a doctor in their network.

Physicians do a history and physical exam and order tests and procedures on patients’ behalf.  When the test and procedures come back physicians prescribe the appropriate medication after a follow-up visit.

The healthcare insurance company reimburses physicians.

  Patients receive a copy of the bill from the insurer with patient portion of the co-pay. The explanations of benefits are impossible to interpret.

This is not a marketplace transaction. Patients have no control over the reimbursement. Patients and physicians have little incentive to restrain overuse of the healthcare system. They have no incentive to even scrutinize the bill. Patients’ have no incentive to control costs.

The use of healthcare services is divorced from marketplace forces that constantly assess cost benefit ratios.  Neither physicians nor patients have incentive to get the best care at the lowest price with the best quality.

As healthcare costs increase each year the source of the increase remains opaque. The increasing costs are made to appear to be the result of patients’ and physicians’ overuse of the healthcare system.

The increase in cost could be the result of the healthcare insurance industry and the pharmaceutical industry’s increased profits.

All stakeholders pursue their vested interests. The only way to align vested interests is to have consumers be responsible for thei health and healthcare dollars.

Only then will a true market place exist. Entitlements and price controls do not work. The cost of healthcare will skyrocket with Obamacare and create a larger budget deficit.

 

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

Please send the blog to a friend 

 

 

 

 

 

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The Healthcare Insurance Industry Is Not Interested in Being Price Transparent.

October 16, 2011
inConsumer Driven Health Care, Healthcare Insurance Industry, Medicine: Healthcare System, Stakeholder Mistrust
• Leave a comment

Stanley Feld M.D.,FACP,MACE

Truthful information (Price Transparency) is a huge issue in the healthcare system. Hospital systems, physicians, drug companies, pharmacies, the healthcare insurance industry and the government hide behind the opacity of information.

There is a mutual distrust among stakeholders.

This mutual distrust must be overcome and price transparency achieved before any progress can occur in Repairing The Healthcare System.

In order to achieve Pareto efficiency in the healthcare system all the stakeholders must agree to price transparency. The advantage of Pareto efficiency is that all the stakeholders will be better off in the long term while some might have to yield to some issues in the short term.

Lodi Hurwicz introduced the idea of incentive compatibility. His point is the way to get as close to the most efficient economic outcomes is to design mechanism in which everyone does best for himself or herself. He says this can be achieved by sharing information truthfully (Price Transparency). It is easy to understand that some people can do better than others by not sharing information or lying.

 The lack of interest in price transparency by the healthcare insurance industry was demonstrated in New York State in the last few weeks.

Major health insurance companies seeking steep premium increases in New York have submitted memos to state officials to justify the higher rates. Now they are fighting to keep the memos from the public, saying they include trade secrets that competitors could use against them.

 Benjamin M. Lawsky, the state superintendent of financial services, whose new agency oversees the state insurance division said,

 “How these companies are setting these rates is vital for the public to know, and should not be treated like a state secret,” “Transparency will promote healthy competition and enable the public to rigorously comment on proposed rates, two goals that all of us should favor.”

 The state insurance division issues permits to healthcare insurance companies to sell insurance in the state. If a healthcare insurance company does not want the state to publish the reasons for its insurance premium increases they should not be issued a permit to sell healthcare insurance in that state.

Mr. Lawsky has ordered that the memos be made public. His decision will go into effect by the end of November unless the companies obtain a court injunction.

The healthcare insurance industry has held the advantage over consumers in the past under the long-standing “trade secret” exemption.  The state legislature should have the courage to eliminate that exemption.

The decision followed a battle by a consumer advocacy coalition, Health Care for All New York, which had first sought information for a policyholder in Queens who faced a 76 percent increase in his family’s Emblem Healthpremium. (The fee was later raised by 270 percent.)

State Insurance Department has received hundreds of consumer protests over proposed premium increases, many of them double-digit percentages without justification except that it must be done. The State Insurance Department now has the power to reject proposed rate increases. The question remains as to whether they have the courage to reject the increases.

Aetna and others are making outrageous profits selling healthcare insurance and paying its executives many millions of dollars a year in salary.

Aetna, like other carriers, has said premium increases are driven by the actual cost of health care. But consumer advocates dispute such assertions, while complaining that it is hard to challenge the increases without access to the company filings.

United Health/Oxford wrote, “This matter is of critical importance to us.” It called the information “proprietary.”

 Aetna wrote,  “Public disclosure in this format will provide ready and easy access to comprehensive pricing, product and marketing strategies,” and warned of “substantial and irreparable injury to Aetna.”

Independent Health said, “It had spent “well over $700,000 developing the trade secret documents” and estimated that the value of keeping them confidential was much higher.

It sounds as if both Aetna and Independent Health are threating the state with legal action. If they do not like the state rule they should move on and not sell insurance in that state.  

The state’s obligation is to protect its consumers from abuse. The state should simply deny permits to the healthcare insurance company to sell healthcare insurance in the state.

Moreover, other companies argued, the filings are too technical to be understood by consumers.

“Several of the exhibits to the rate application as well as the actuarial memorandum contain not only trade secrets as noted above, but esoteric actuarial pricing precepts best understood by fellow actuaries and health plan competitors,” Sean M. Doolan, a lawyer representing Excellus, Empire, Connecticut General, and Capital District Physicians’ Health Plan wrote to state officials.

 “These documents, often speaking of concepts such as morbidity and anti-selection, could cause not only confusion, but also unnecessary alarm to the layman policyholder.”

These are excuses. They are lame and patronizing. Consumers are not as dumb as the insurance industry thinks.

 Elisabeth Benjamin is vice president for health initiatives at the Community Service Society of New York and a founder of Health Care for All New York, a coalition of 100 groups working for more affordable medical care. She said the group has hired its own actuaries.

“The only way the public will find out whether these outlandish price hikes are justified is if we can see the underpinnings,” she said. “They would like to have us ignorant. What they are saying to us, by opposing the disclosure of why they think their rate increases are justified, is that they want to keep us uninformed consumers.”

They sure do want to keep consumers ignorant. I hope the state officials are not intimidated by the healthcare insurance companies. I hope the state officials are supported by New York’s governor. Consumers are starting to understand their power. They need to drive the healthcare system. This issue is a good place to start.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.  

 

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The Healthcare System and Managing Complexity

October 5, 2011
inDisinformation and the healthcare system, Information Technology in Healthcare, Innovations in Healthcare, Medicine: Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D.,FACP, MACE

 Many readers were confused by my last four blogs, It Is Easy To Forget, How To Manage Complexity, Aligning Incentives Is A Must In Creating An Efficient Healthcare System and How Home Depot Learned To Manage Complexity.

I have received comments like, What does this have to do with the healthcare system? Who cares about Mechanism Design? What does the healthcare system have to do with Pareto efficiency?

One person wrote; “Dr. Feld, I do not get it. None of this relates to the healthcare system.”

All of these blogs relate to the dysfunction in the healthcare system. The healthcare system has a larger “Blind Spot” than many large corporations in America. 

My brother and I have been discussing his analysis of the Blind Spot in corporate America in detail. The subtitle of his book is “A Leader’s Guide To IT-Enabled Business Transformation.”

It dawned on me that his transformation model could be applied to the healthcare system. Everyone knows the healthcare system has to be fixed but no one knows what to do.

President Obama and Dr. Don Berwick are making the dysfunction worse as they impose their complicated ideas on the healthcare system.

A reader wrote in response to my Home Depot article,

 

“Yeah, this is good stuff–consumer oriented.  Obama & those ox#70 professors he listens to don't get this at all.” 

I often get comments that the Healthcare System is impossible to repair. It is too complex.

Medicine is going through a transformation. There is conflict between vested interests and between learning systems.

1. Stakeholders are fighting to protect their vested interests. The fight has intensified as a result of the transformation. The conflicts must be resolved.

2. Physicians continually learn through the experience of daily medical practice. The experience gained increases physicians’ medical judgment. This learning system is important for the physician-patient relationship. It promotes the confidence patients should have in their physicians.

 As a result of the dysfunction in the system physicians are abandoning their medical judgment in the pursuit of defensive medicine and patients are losing confidence in their physician’s judgment.

Data should be accurate and informative for patients and physicians to improve care. Instead the data collected has been punitive to both patients and physicians.

3. Advances in medical science and medical technology represent complicated learning systems. New advanced techniques are developed in surgery, medicine, genetics and therapeutics.

Information technology offers a chance to enhance experiential learning but has not been deployed properly. Instead it has led to disinformation and increased stakeholder mistrust.

Healthcare insurance companies, hospital systems, and the government have installed complicated data collecting information systems to gather insight into the cost and quality of medical care.

In the past, much of the data has not reflected the true value of the care of physicians. The data has been used to the disadvantage of patients and physicians.

4. No one has understood the patterns of behavior that have resulted from these conflicting learning systems and vested interests. No one has figured out how to manage the complexity generated by these interactions in the healthcare system.

The Home Depot example of learning to manage complexity can be applied to the healthcare system.

The physician is the store manager. The patient is the customer.  All the rest of the stakeholders should be the supporting cast.

Once everyone gets it, a sensible conversation can begin. Only then can the healthcare system be on its way to achieving Pareto efficiency.

Readers should think about their recent healthcare system encounters. I would guess many have walked away with an unpleasant feeling toward the healthcare system whether it was the encounter with the insurance company, hospital, government, pharmacy, or physician.

 Navigating the healthcare system has become an unpleasant chore.

It is also unpleasant for all the stakeholders. Yet none of the stakeholders see their Blind Spot.

These unpleasant and inefficient activities are created by the complexity of the healthcare system. This complexity can be broken down into components parts. Only then can the complexity of the healthcare system be managed. 

The most important asset all of us own is our health. Every effective effort must be made by the healthcare system to maintain our health. We as individuals must be responsible for maintaining our health.  Individual responsibility can be achieved.  When it is everyone will win.

Central control of our healthcare system with government imposition of rules and regulations to control patients’ freedom and physicians’ medical judgments will not work.

   

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.  

 

 

 

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Aligning Incentives Is A Must In Creating An Efficient Healthcare System

September 28, 2011
inMedicine: Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

 Mechanism Design has demonstrated that the most efficient systems are created when everyone’s vested interests are aligned.

 

“An example is defense contracting. If you agree to pay on a cost plus basis you have created incentive for the contractor to be inefficient.

The defense contractor will build enough extra into a fixed price system to account for cost overruns.  The cost overrun would be permitted in the rules if the price was transparent. If there were no cost overruns the contractor’s profit would be increased. It would provide incentive to be efficient.

 “If you agree to pay a fixed price, you can come close to an efficient price if you have all the truthful information.”

A reader wrote’

Stanley:

History has proven over and over again that only the market mechanism of willing sellers and willing buyers is the optimal way to allocate economic resources. This presumes an informed buyer, and a willingness of sellers to compete for buyers. Adam Smith was clear on this in the Wealth of Nations.
 

If incentives are aligned and truthful price information is available an efficient system is created.  Most stakeholders think they can do better by not sharing truthful information. If the rules of the game require truthful information the system can become an efficient market driven solution.

The healthcare system must become market driven. At present the healthcare system is an artificially distorted free market system. Government intervention has distorted and made the free market inefficient.  

The distorted free market has led to higher prices.

The concept of Pareto efficiency implies one stakeholder has to yield something which makes another stakeholder better off. The reality is in an efficient system the first stakeholder is worse off than he/she theoretically could be.

The first stakeholder yielding makes him/her better off than he/she is but still worse than he/she could theoretically be. The temptation is to not be truthful in order to maintain dominance at the expense of others.

 Leoid Hurwicz observed as others had that the dispersion of information was at the heart of the failure of a planned economy. He observed that there was a lack of incentive for people to share their information with the government truthfully.

 The free market mechanism was far less afflicted than central planning bureaucracy by such incentive problems. The free market economy was by no mean immune to this defect.

He observed that the free market economy can get us closer than central planning to incentive compatibility because the end consumer can drive the discovery of truthful information.

This can explain the power of my Ideal Medical Savings Account.

Consumers creating rules of engagement in a market driven economy can get closest to ideal Pareto efficiency. Since customers determine success of an enterprise by creating demand in a transparent environment, they can get closer to an efficient system.

Consumers can create the rules of the game for compatible incentives. Consumers must have the appropriate financial incentives to maintain their health. They must also own their healthcare dollars.

The government should help consumers design the rules of the game and then get out of the way. The rules should be designed so the patient is first. 

At present the insurance industry is taking advantage of the patients, doctors and hospital systems. The hospital systems are taking advantage of the patients, doctors and insurance companies. Doctors are taking advantage of the insurance companies, hospital systems, patients and the government. The government is taking advantage of the hospital systems, the doctors and the patients. Everyone is pursuing his or her own vested interest at the expense of other stakeholders.

 The insurance companies take advantage of employers.  The drug companies are taking advantage of patients and unduly influencing physicians.

In our healthcare system everyone is pursuing his vested interest in a game that has rules that do not lead to “incentive compatibility.”

Some politicians think central planning can result in producing effective rules and appropriate controls.

Historically, central planning has not worked. 

Before effective healthcare reform can take place, rules acceptable to all the stakeholders must be in place. Stakeholders must create price transparency and understand the value of compromise.

It must be understood why it is important that consumers drive the healthcare system and not the central government. Only consumers can create an undistorted efficient market driven system.

Consumers have to have be empowered and given incentives to align all the stakeholders’ incentives. The best and easiet program to achieve this goal is my ideal medical saving account.

 The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone. 

 

 

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The Healthcare Insurance Industry Continues To Game The Healthcare System

August 28, 2011
inDisinformation and the healthcare system, Medicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

I have described how the healthcare insurance industry loads its expenses into direct patient care expenses to increase their profits. 

The Medical-Loss Ratio calculation of is not reported by the traditional media. The healthcare insurance industry spends less healthcare dollars on direct patient care after it is permitted by federal and local agencies to load its expenses into the direct patient care column.

Simply put, the healthcare insurance industry cooks the books to increase its net profit.

Another way to increase profits is to shortchange physicians on medical claims. In fact, 20% of medical claims payments are inaccurate according to the American Medical Association’s (AMA) fourth annual National Health Insurer Report Card. Claims-processing errors by health insurance companies waste billions of dollars and frustrate patients and physicians.

This is one of the reasons the RAND report about physicians controlling waste is so absurd to me.  The healthcare insurance industry creates waste in order to increase net profit.

 The AMA released its annual report card on insurers saying, "Eliminating mistakes would save doctors and insurers $17 billion a year." 

The AMA said, “Commercial health insurance companies have an error rate of 19.3 percent, up two percentage points from last year's report.”

The healthcare insurance industry’s computer systems become better each year. At the same time, the healthcare industry has a higher error rate each year.

 The healthcare insurance industry’s explanation of benefits becomes less comprehensible to patients and physicians every year.

 When physicians discover insurers’ mistakes in reimbursement they fight the healthcare insurer for their patients or themselves. It is costly to fight and it distracts physicians from their job of diagnosing and treating patients. 

I think the error rate in reimbursement is even higher than reported. A significant percentage of physicians or their billing services do not pick up many of the errors.

The 2011 report card is based on a random sampling of about 2.4 million electronic claims for approximately four million medical services submitted in February and March 2011 to Aetna, Anthem Blue Cross Blue Shield, Cigna, Health Care Service Corp., Humana, the Regence Group, UnitedHealthcare and, for comparison, Medicare, according to the AMA.

 The claims were gathered from more than 400 physician practice groups in 80 medical specialties in 42 states.

It must be recognized that the random sample is a small percentage of the total number of claims processed. The results can have a large margin of error and result in a higher percentage of mistakes.

“The increase in overall inaccuracy represents an extra 3.6 million in erroneous claims payments compared to last year, and added an estimated $1.5 billion in unnecessary administrative costs to the health system.”

The additional administrative costs have an insurance industry’s profit component added on to reprocessing the errors.

 Why hasn’t President Obama recognized this and gone after this abuse of the healthcare system?

 "Robert Zirkelbach, spokesman for America's Health Insurance Plans, said in an e-mailed response that insurers and providers share the responsibility of improving claims payment accuracy and efficiency." 

The response is lame. The response gets worse.

 "CIGNA maintained its industry leading low denial rate of 68 percent." Notably, "lack of patient eligibility for medical services continues to be the most frequent reason for denials." 

UnitedHealthcare was the only commercial health insurer included in this year’s report card to demonstrate an improvement in claims-processing accuracy.

UnitedHealthcare came out on top of seven leading commercial health insurers with a accuracy rating of 90.23 percent. Anthem Blue Cross Blue Shield had scored the worst of those measured with an accuracy rating of 61.05 percent.  

Insurer Non-payment. 

 Physicians’ total non-payment rate for claims submitted to all commercial healthcare insurer was almost 23%. There is no reason insurance claims should not be adjudicated at the point of service. 

The insurance industry uses non-payment to hold onto the float. It results in hassling physicians and patients. Physicians are starting to demand full payment for services at the point of service from patients. This leaves adjudication of claims to the insurance company and patients. It can represent a hardship to patients. 

Denials

 Aetna, Anthem Blue Cross Blue Shield, Health Care Service Corporation and UnitedHealthcare cut denial rates in half in one year to 1.05 percent as a result of last year’s AMA report card. 

Administrative Requirements. 

There is an increase in the rate of claims requiring prior authorization. Physicians have to ask permission before performing services or treatments. 

This increased requirement has many effects. It undermines the physician patient relationship and the patient’s confidence in the physician. It delays or interrupts medical services to patients. It consumes a significant amount of the physician’s time. It complicates medical decisions. It should be patients who question their physician’s decisions and have their physician justify the treatment to them. 

Accuracy

The healthcare insurance industry agrees to contracted reimbursement fees. The fees vary depending on how much the healthcare insurance company needs particular physicians in its network. Healthcare insurers have been notorious about not processing claims accuracy.  

It seems to me that with the state of the art of information technology being what it is, contracted fee reimbursement should be automatic and accurate. Most insurers have gotten better over the last year.

“The exception was Anthem Blue Cross Blue Shield, which scored 14 percent lower on this measure than it did four years ago.”

This is inexcusable. It might be purposeful in communities where Anthem Blue Cross Blue Shield is the dominant insurer.

Timeliness.

The AMA report card has been effective in exposing response time for adjudication of claims by physicians to the healthcare insurance company. CIGNA and Humana have cut their median claims response time in half in the last four years.

 Response times varied for commercial health insurers from six to 15 median days.

The resulting waste in the healthcare system from all of these tactics is enormous. Total healthcare insurance industry administrative waste (unnecessary expenses) is about $150 billion dollars a year.

If President Obama really wanted the present system of employer sponsored insurance to survive, he would be putting resources toward solving these problems.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.